Archive for the ‘Deep Vein Thrombosis (DVT)’ Category

Stephan Moll, MD writes…Can the patient with acute DVT or PE safely fly, or should he/she wait for a few weeks before embarking on airline travel? It appears safe to fly early: There is no evidence that flying early after the diagnosis of VTE leads to an increased risk of recurrent VTE or embolization from a DVT, as long as the patient is on adequate anticoagulation.

Airline travel and Thrombosis

a) The person NOT on anticoagulation

Airline travel is an established (mild) risk factor for DVT and PE in the patient who is NOT on anticoagulation [1,2]; the longer the travel, the higher the risk for thrombosis [1]. Typically, multiple risk factors come together –overweight, hormone therapy (e.g. contraceptives), recent surgery, trauma, or hospital stay, cancer, genetic or acquired clotting disorders, and the immobility from the travel itself. It has also been suggested that the hypobaric atmosphere in the airplane cabin might lead to coagulation activation and an increased risk for VTE, particularly in persons with one or more of the above underlying risk factors for VTE [ref 4], but neither have data on this issue been consistent, nor is it clear whether such changes are clinically relevant.

b) The patient with VTE who is on anticoagulation

Is there an increased risk for recurrent DVT or PE or embolization from a DVT? It is not known whether the risk for recurrent VTE or the risk for a DVT to embolize is increased with airline travel in the patient who is on anticoagulation for a previous VTE. Any potential coagulation activation by the hypobaric cabin environment is likely counteracted by the fact that the patient is on anticoagulation. Thus, an increased anticoagulation failure rate (i.e. progression of DVT or PE; increased risk of DVT leading to PE) is not likely. And while the reduction in ambient cabin pressure per se leads to a small reduction in a patient’s partial pressure of oxygen (PO2) and this may lead to mild vasodilatation and an increase in cardiac output, this is not likely to increase the risk of embolization from a DVT.

Do patients with DVT develop increased leg swelling while flying? The patient with acute DVT (or postthrombotic syndrome) and leg swelling may experience somewhat more leg swelling during or after the flight – because of leg edema from an increase in capillary permeability in the hypobaric cabin environment, not because of DVT progression. Also, the distances to walk and the prolonged standing in the airport may lead to worsened leg edema. However, this is not expected to lead to progressive or recurrent DVT.

Do patients with PE develop increased shortness of breath while flying?The patient who has a large PE or has other underlying hypoxic lung disease (COPD, etc.) may have some worsening of shortness of breath during flying – not because of new PE, but because the cabin’s environment is mildly hypoxic.

Background Data

Rules by the International Air Transportation Association (IATA) limit the decrease in cabin pressure in commercial aircraft to an equivalent altitude of 8,000 ft (564 mmHg, 0.74 ATA), although most planes maintain their pressures at an equivalent altitude of around 5,000 ft (632 mmHg, 0.83 ATA). Thus, the predicted decrease in a patient’s arterial PO2 is small, and would be clinically significant only for people with pre-existing hypoxemia.

My Approach

In general, I discuss with the patient who has an acute DVT or PE and wants to fly soon that…

he/she can fly, even immediately after the VTE diagnosis, as long as he/she is on full-dose anticoagulation.

that airline travel is not expected to lead to an increased risk of recurrent VTE or embolization from a DVT.

leg swelling in the patient with DVT may temporarily worsen during and in the few days after airline travel due to the hypobaric pressure in the airline cabin.

shortness of breath in the patient with a large PE may be somewhat worse during airline travel due to the mildly decreased oxygen content in the airline cabin.

it may be worthwhile to delay a flight for at least a few days to be sure that the patient is stable, no unexpected issues occur, and/or the patient has had time to adapt to this new, potentially life-modifying diagnosis and treatment.

Stephan Moll, MD writes… An article for patients discussing (a) IVC filters, (b) narrowing of the main left pelvic vein (May-Thurner syndrome) and (c) pelvic venous stents has just been published (http://circ.ahajournals.org/content/133/6/e383.full.pdf). Color images of anatomy, filters and stents are included as visual aids. The article may be helpful as handout material for patients in clinic.

Stephan Moll, MD writes… An information article on various aspects of thrombophilia, written for patients and family members, was published today – available here– as a Vascular Disease Patient Information Page in the journal Vascular Medicine.It addresses (a) in which patient with venous thromboembolism to consider thrombophilia testing, (b) what tests might be appropriate to do, (c) how the test results might influence length of anticoagulation therapy (d), what contraceptives are safe to use in women with a history of DVT or PE or thrombophilia, and (e) in which family members to consider thrombophilia testing. This article can be used as an education handout for patients in clinic or the hospital who have DVT, PE, venous thrombosis in unusual locations, or an established thrombophilia.

Stephan Moll, MD writes (Dec 17, 2014)… The American Society of Hematology (ASH) published last week as part of its Choosing Wisely® campaign two things that physicians dealing with DVT, PE and anticoagulants should avoid [ref 1]. Read the rest of this entry »

Stephan Moll, MD writes… This week (Feb 18th, 2014) a guidance document on the prevention and management of catheter-associated upper extremity (brachial, axillary, subclavian, and brachiocephalic veins) and neck (internal jugular) DVT was published by the International Society for Thrombosis and Haemostasis (ISTH) [ref 1]. The authors acknowledge that optimal long-term management of catheter-associated DVT has not been established. The key recommendations: Read the rest of this entry »

Stephan Moll, MD writes… Patients who are on warfarin for a history of DVT or PE may inquire whether a switch to one of the new oral anticoagulants is appropriate. Similarly, many physicians initiate this discussion with their patients.

This is, obviously, a detailed discussion and an individualized decision with a number of factors to be considered. We have developed a two-page “Comparison of Oral Blood Thinners” handout for patients, to assist with and summarize the discussion. This sheet allows a structured discussion with the patient about the pros and cons of the various anticoagulant choices. The reader is welcome to print this resource and use it as a handout for his/her patients.

Disclosure: I have been a consultant for Boehringer-Ingelheim, Daiichi, and Janssen.

Stephan Moll, MD writes… A major international coagulation conference, the bi-annual meeting of the International Society for Thrombosis and Haemostasis (ISTH; www.isth.org), took place in Amsterdam, Holland, from June 29th to July 4th, 2013. The clinically relevant highlights about thrombosis and anticoagulation are summarized below. Read the rest of this entry »

An important study (AMPLIFY trial) was published today in the New England Journal of Medicine [ref 1]: In a large study of 5395 patients with acute DVT or PE, Eliquis (apixaban) was as effective as warfarin and caused less major bleeding. Read the rest of this entry »

2012 has been a year with significant progress in the field of venous thromboembolism and anticoagulation. The three most noteworthy, clinically relevant developments were probably (a) the publication of the new ACCP (American College of Chest Physician) guidelines on antithrombotic therapy in February 2012; (b)The FDA-approval of rivaroxaban (Xarelto) in November 2012 for the acute treatment of venous thromboembolism (VTE) and long-term secondary prevention; and (c)The FDA-approval of apixaban (Eliquis) in December 2012 for atrial fibrillation and the prevention of arterial thromboembolism. Here I have listed and summarized the 10 top publications of 2012 in the field of venous thromboembolism and anticoaguation as I see them – the ones clinically most relevant.

Disclosure: I have consulted for Janssen, Boehringer-Ingelheim and Daiichi.